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Laitinen MK. CORR Insights®: How Does Customized Cutting Guide Design Affect Accuracy and Ergonomics in Pelvic Tumor Resection? A Study in Cadavers. Clin Orthop Relat Res 2024; 482:1003-1005. [PMID: 38502816 PMCID: PMC11124704 DOI: 10.1097/corr.0000000000003048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Affiliation(s)
- Minna K Laitinen
- Head of the Orthopaedic and Traumatology Department, Helsinki University Central Hospital, Helsinki, Finland
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2
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Keskinis A, Paraskevopoulos K, Diamantidis DE, Ververidis A, Fiska A, Tilkeridis K. The Role of 3D-Printed Patient-Specific Instrumentation in Total Knee Arthroplasty: A Literature Review. Cureus 2023; 15:e43321. [PMID: 37700954 PMCID: PMC10493459 DOI: 10.7759/cureus.43321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Total knee arthroplasty (TKA) is currently one of the most common orthopedic surgeries due to the ever-increasing average life expectancy. The constant need for effective and accurate techniques was contributed to the development of three-dimensional (3D) printing in that field, especially for patient-specific instrumentation (PSI) and custom-made implants fabrication. PSI may offer numerous benefits, such as resection accuracy, mechanical axis alignment, cost-effectiveness, and time economy. Nonetheless, the results of existing studies are controversial. For this purpose, a review article of the published articles was conducted to summarize the role of 3D-printed PSI in TKA.
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Affiliation(s)
- Anthimos Keskinis
- Orthopedic Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, GRC
| | - Konstantinos Paraskevopoulos
- Orthopedic Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, GRC
| | | | - Athanasios Ververidis
- Orthopedic Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, GRC
| | - Aliki Fiska
- Anatomy Laboratory, Democritus University of Thrace, Alexandroupolis, GRC
| | - Konstantinos Tilkeridis
- Orthopedic Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, GRC
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Minimum 5-Year Outcomes of a Multicenter, Prospective, Randomized Control Trial Assessing Clinical and Radiological Outcomes of Patient-Specific Instrumentation in Total Knee Arthroplasty. J Arthroplasty 2022; 37:1579-1585. [PMID: 35077818 DOI: 10.1016/j.arth.2022.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patient-specific instrumentation (PSI) was developed to produce more accurate alignment of components and consequently improve clinical outcomes when used in total knee arthroplasty. We compare radiological accuracy and clinical outcomes at a minimum of 5-year follow-up between patients randomized to undergo total knee arthroplasty performed using PSI or traditional cutting block techniques. METHODS This multicenter, randomized control trial included patients blinded to the technique 1used. Outcome measures were coronal alignment measured radiologically, Euroqol-5D, Oxford knee score, and International Knee Society Score measured at 1- and 5-year follow-up. RESULTS At a minimum 5-year follow-up, there were 38 knees in the PSI group and 39 in the conventional instrumentation group for analysis. Baseline demographics and clinical outcome scores were matched between groups. Overall, there was no significant difference in the coronal femoral angle (P = .59), coronal tibial angle (P = .37), tibiofemoral angle (P = .99), sagittal femoral angle (P = .34), or the posterior tibia slope (P = .12) between knees implanted using PSI and those implanted with traditional cutting blocks. On the measurement of coronal alignment, intraobserver reliability tests demonstrated substantial agreement (k = 0.64). Clinical outcomes at both 1-year and 5-year follow-up demonstrated statistically significant and clinically relevant improvement in scores from baseline in both groups, but no difference could be detected between the Euroqol-5D (P = .78), Oxford knee score (P = .24), or International Knee Society Score (P = .86) between the 2 groups. CONCLUSION This study has shown no additional benefit to PSI in terms of improved alignment or functional outcomes at minimum 5-year follow-up over traditional techniques.
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Sasaki U, Tamaki M, Tomita T, Okada S. Total Knee Arthroplasty With Patient-Specific Instrumentation to Correct Severe Valgus Deformity in a Patient With Hereditary Multiple Exostoses. Arthroplast Today 2022; 16:175-181. [PMID: 35789783 PMCID: PMC9249969 DOI: 10.1016/j.artd.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 04/03/2022] [Accepted: 04/27/2022] [Indexed: 11/05/2022] Open
Abstract
Patients with hereditary multiple exostosis develop several benign osseocartilaginous bulge lesions throughout the body. A 62-year-old woman presented for evaluation of worsening left knee valgus deformity, and left knee pain. She had been diagnosed with hereditary multiple exostosis at the age of 12 years. Radiographic evaluation of the left knee revealed exostoses that caused continuous bulges from cortical bone at the metaphyseal regions of the femur and tibia as well as extra-articular deformity. We used patient-specific instrumentation to indicate the direction of the stem into curved metaphyseal bone regions and then corrected the patient’s left knee deformity by performing total knee arthroplasty with titanium-constrained prostheses. Soft tissue release was performed with only complete iliotibial band release at a minimum, and stability was obtained.
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Kazarian GS, Haddad FS, Donaldson MJ, Wignadasan W, Nunley RM, Barrack RL. Implant Malalignment may be a Risk Factor for Poor Patient-Reported Outcomes Measures (PROMs) Following Total Knee Arthroplasty (TKA). J Arthroplasty 2022; 37:S129-S133. [PMID: 35248754 DOI: 10.1016/j.arth.2022.02.087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Implant malalignment may be a risk factor for poor patient-reported outcomes measures (PROMs) following total knee arthroplasty (TKA). METHODS Postoperative surveys were administered to assess PROMs regarding satisfaction, pain, and function in 262 patients who underwent surgery at 4 centers in the U.S. and U.K (average age, 67.2) at a mean 5.5 years after primary TKA. Postoperative distal femoral angle (DFA), proximal tibial angle (PTA), and posterior tibial slope angle (PSA) were radiographically measured, and outliers were recorded. PROMs were compared between patients with aligned versus malaligned knees using univariate analysis. RESULTS Patients with DFA, PTA, and PSA outliers were more likely to experience similar or decreased activity levels postoperatively than patients with no alignment outliers, as were patients with 1 or 2 outliers of any kind (P < .05). Patients with DFA, PTA, and PSA outliers were significantly more likely to be dissatisfied with their ability to perform activities of daily living (ADLs), as were patients with 1 or 2 outliers of any kind (P < .05). Patients with DFA and PSA outliers were more likely to be dissatisfied with their degree of pain relief, as were patients with 2 outliers of any kind (P < .05). Finally, patients with DFA and PSA outliers, as well as those with 1 outlier of any kind, were more likely to be dissatisfied with their overall knee function (P < .05). CONCLUSION DFA, PTA, and PSA outliers represent a significant risk factor for decreased satisfaction with activities of daily living(ADLs), pain relief, and knee function, as well as decreased activity levels. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Gregory S Kazarian
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO; Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Fares S Haddad
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO
| | - Matthew J Donaldson
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO
| | - Warran Wignadasan
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO
| | - Ryan M Nunley
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO
| | - Robert L Barrack
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO
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Hasan S, Kaptein BL, Nelissen RGHH, van Hamersveld KT, Toksvig-Larsen S, Marang-van de Mheen PJ. The Influence of Postoperative Coronal Alignment on Tibial Migration After Total Knee Arthroplasty in Preoperative Varus and Valgus Knees: A Secondary Analysis of 10 Randomized Controlled Trials Using Radiostereometric Analysis. J Bone Joint Surg Am 2021; 103:2281-2290. [PMID: 34648477 DOI: 10.2106/jbjs.20.01659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Orthopaedic surgeons aim for mechanical alignment when performing total knee arthroplasty (TKA) as malalignment is associated with loosening. Loosening may be predicted by migration as measured with radiostereometric analysis (RSA), but previous RSA studies on postoperative alignment have shown contradictory results and have been limited to cemented implants and small numbers of patients. Therefore, we performed a secondary analysis of 10 previously published randomized controlled trials (RCTs) to compare migration between postoperative in-range and out-of-range cemented and uncemented TKA implants among patients with a preoperative varus or valgus knee. METHODS All RCTs involving the use of RSA that had been conducted at 2 centers were included. Alignment was classified, with use of the hip-knee-ankle angle (HKA), as in-range (0° ± 3°) or out-of-range (<-3° or >3°). The fixation methods included cemented, uncemented-coated, and uncemented-uncoated. Migration was measured at 3, 12, and 24 months. A linear mixed model was used, with adjustment for fixation method and clustering of patients within centers. RESULTS Of 476 TKA implants that had been out-of-range preoperatively, 290 were in-range postoperatively and 186 were out-of-range in either varus (n = 143) or valgus (n = 43) postoperatively. The mean migration at 3, 12, and 24 months was 0.73 mm (95% confidence interval [CI], 0.66 to 0.79 mm), 0.92 mm (95% CI, 0.85 to 1.00 mm), and 0.97 mm (95% CI, 0.90 to 1.05 mm), respectively, for the in-range group and 0.80 mm (95% CI, 0.72 to 0.87 mm), 0.98 (95% CI, 0.90 to 1.07 mm), and 1.04 mm (95% CI, 0.95 to 1.13 mm), respectively, for the out-of-range group (p = 0.07). The fixation method significantly influenced migration, with uncemented-uncoated implants migrating more than cemented and uncemented-coated implants (p < 0.001). CONCLUSIONS Postoperative alignment did not influence migration of TKAs in the first 2 postoperative years in patients with preoperative varus or valgus alignment of the knee. However, the fixation method significantly influenced migration, with uncemented-uncoated implants showing the greatest migration. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Shaho Hasan
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart L Kaptein
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Koen T van Hamersveld
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Sören Toksvig-Larsen
- Department of Orthopaedics, Hässleholm Hospital, Hässleholm, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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Comparison of Postoperative Coronal Leg Alignment in Customized Individually Made and Conventional Total Knee Arthroplasty. J Pers Med 2021; 11:jpm11060549. [PMID: 34204771 PMCID: PMC8231644 DOI: 10.3390/jpm11060549] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/29/2022] Open
Abstract
Neutral coronal leg alignment is known to be important for postoperative outcome in total knee arthroplasty (TKA). Customized individually made implants (CIM) instrumented with patient-specific cutting guides are an innovation aiming to increase the precision and reliability of implant positioning and reconstruction of leg alignment. We aimed to compare reconstruction of the hip–knee–ankle angle (HKA) of the novel CIM system iTotal™ CR G2 (ConforMIS Inc.) to a matched cohort of the off-the-shelf (OTS) knee replacement system Vanguard™ CR (Zimmer Biomet). Retrospective analysis of postoperative coronal full-leg weight-bearing radiographs of 562 TKA (283 CIM TKA, 279 OTS TKA) was conducted. Via a medical planning software, HKA and rotation of the leg were measured in postoperative radiographs. HKA was then adjusted for rotational error, and 180° ± 3° varus/valgus was defined as the target zone HKA. Corrected postoperative HKA in the CIM group was 179.0° ± 2.8° and 179.2° ± 3.1° in the OTS group (p = 0.34). The rate of outliers, outside of the ±3° target zone, was equal in both groups (32.9%). Our analysis showed that TKA using patient-specific cutting guides and implants and OTS TKA implanted with conventional instrumentation resulted in equally satisfying restoration of the coronal leg alignment with less scattering in the CIM group.
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Moorthy V, Chen JY, Liow MHL, Chin PL, Chia SL, Lo NN, Yeo SJ. Mid-term functional outcomes of patient-specific versus conventional instrumentation total knee arthroplasty: a prospective study. Arch Orthop Trauma Surg 2021; 141:669-674. [PMID: 33386974 DOI: 10.1007/s00402-020-03729-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/06/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Patient-specific instrumentation (PSI) utilizes three-dimensional imaging to produce total knee arthroplasty cutting jigs which matches patient's native anatomy. However, there are limited mid- to long-term studies examining its clinical efficacy. The aim of this study was to compare functional outcomes of PSI surgery versus conventional TKA surgery at 5-year follow-up. MATERIALS AND METHODS Sixty patients were prospectively recruited into either the MRI-based PSI or conventional TKA group. Functional outcomes were assessed using the Knee Society Function Score (KSFS), Knee Society Knee Score (KSKS) and Oxford Knee Score (OKS), while quality of life was evaluated with the Physical Component Score (PCS) and Mental Component Score (MCS) of Short-Form 36 and compared between the two groups at 5-year follow-up. RESULTS Although the PCS was 7 ± 3 points better in the PSI group preoperatively (p = 0.017), it became 5 ± 2 points worse than the conventional group at 5-year follow-up (p = 0.025). As compared to the PSI group, the conventional group showed a significantly greater improvement in PCS at 5 years as compared to before surgery (p = 0.003). There were no significant differences in KSFS, KSKS, OKS or MCS between the two groups. CONCLUSIONS PSI TKA did not result in improved functional outcomes or better quality of life when compared to conventional TKA. The additional costs and waiting time associated with PSI are not justifiable and therefore not recommended as an alternative to conventional TKA. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Vikaesh Moorthy
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore.
| | - Jerry Yongqiang Chen
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
| | - Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
| | - Pak Lin Chin
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
| | - Shi-Lu Chia
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
| | - Ngai Nung Lo
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
| | - Seng Jin Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
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Kumar P, Vatsya P, Rajnish RK, Hooda A, Dhillon MS. Application of 3D Printing in Hip and Knee Arthroplasty: A Narrative Review. Indian J Orthop 2020; 55:14-26. [PMID: 34122751 PMCID: PMC8149509 DOI: 10.1007/s43465-020-00263-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/14/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Ideal surgical positioning and placement of implants during arthroplasty are crucial for long-term survival and optimal functional outcomes. Inadequate bone stock or defects, and anatomical variations can influence the outcomes. Three-dimensional printing (3DP) is an evolving technology that could provide patient-specific instrumentation and implants for arthroplasty, taking into account anatomical variations and defects. However, its application in this field is still not adequately studied and described. The present review was conceptualised to assess the practicality, the pros and cons and the current status of usage of 3DP in the field of hip and knee arthroplasties and joint reconstruction surgeries. METHODS A PubMed database search was conducted and a total number of 135 hits were obtained, out of which only 30 articles were relevant. These 30 studies were assessed to obtain the qualitative evidence of the applicability and the current status of 3D printing in arthroplasty. RESULTS Currently, 3DP is used for preoperative planning with 3D models, to assess bone defects and anatomy, to determine the appropriate cuts and to develop patient-specific instrumentation and implants (cages, liners, tibial base plates, femoral stem). Its models can be used for teaching and training young surgeons, as well as patient education regarding the surgical complexities. The outcomes of using customised instrumentations and implants have been promising and 3D printing can evolve into routine practice in the years to come. CONCLUSION 3D printing in arthroplasty is an evolving field with promising results; however, current evidence is insufficient to determine significant advantages that can be termed cost effective and readily available.
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Affiliation(s)
- Prasoon Kumar
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pulak Vatsya
- Department of Orthopaedics, All India Institute of Medical Science, New Delhi, India
| | - Rajesh Kumar Rajnish
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Hooda
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep S. Dhillon
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Thijs E, Theeuwen D, Boonen B, van Haaren E, Hendrickx R, Vos R, Borghans R, Kort N, Schotanus MGM. Comparable clinical outcome and implant longevity after CT- or MRI-based patient-specific instruments for total knee arthroplasty: a 2-year follow-up of a RCT. Knee Surg Sports Traumatol Arthrosc 2020; 28:1821-1826. [PMID: 31270591 DOI: 10.1007/s00167-019-05616-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Patient-specific instruments (PSI) are already widespread used in total knee arthroplasty (TKA). Either computed tomography (CT) scans or magnetic resonance imaging (MRI) scans are used pre-operatively to create jigs to guide resection during surgery. This study is a sequel of previous work that showed significantly more radiological outliers for posterior slope when CT-based guides were used. The aim of this study was to assess differences in revision rate and clinical outcome between the two groups at 2-year follow-up. METHODS At the 2-year follow-up, 124 patients were analysed in this prospective, randomised single-blind study. A survival analysis with revision of the TKA as endpoint was performed. Patients fulfilled four patient-reported outcome measurements (PROMs). Scores on the questionnaires were compared between both groups at the different follow-up visits. RESULTS At final follow-up, there was no significant difference in the survival rates of the CT- and MRI-based PSI surgery. Postoperatively, the PROMs significantly improved within each group compared with the pre-operative values. There were no significant differences for the PROMs between both groups at the 2-years follow-up. CONCLUSIONS Although previous results showed more outliers regarding posterior slope for CT-based PSIs, no difference in revision rate or the outcome of PROMs was found at 2-year follow-up. Further research to determine what the influence is of radiological outliers on implant survival and clinical outcomes is necessary. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Elke Thijs
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Dieuwertje Theeuwen
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Bert Boonen
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Emil van Haaren
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Roel Hendrickx
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Rein Vos
- Department of Methodology and Statistics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rob Borghans
- Department of Radiology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | | | - Martijn G M Schotanus
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands.
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Abstract
Three-dimensional (3-D) printing technology is affecting how orthopaedic surgeries are planned and executed. Like many innovations, 3-D printers are becoming smaller, more affordable, and more accessible. Free access to open-source 3-D imaging software has also made clinical implementation of this technology widely feasible. Within the last decade, 3-D printing advancements have improved the way orthopaedic surgeons can approach both common and complex cases. Advanced imaging studies can be used to create musculoskeletal models, which can then be used to create custom orthopaedic guides and instruments. Similarly, 3-D printing is being applied to improve the field of biologic therapies in orthopaedics. Application of 3-D printing technology has been associated with important improvements in education, preoperative planning, surgical care, and patient-specific devices and treatments. Improvements in cost-effectiveness, access, and usability of 3-D printing technology have made it possible for orthopaedic surgeons to use this powerful tool using desktop 3-D printers in their clinic or office. The types of printers and materials available to print are constantly expanding, but many of the basic 3-D printing principles persist throughout these advances in the field. A clear understanding of this technology is important to the clinical implementation of 3-D printing for current and future practice of orthopaedic care.
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Kazarian GS, Lawrie CM, Barrack TN, Donaldson MJ, Miller GM, Haddad FS, Barrack RL. The Impact of Surgeon Volume and Training Status on Implant Alignment in Total Knee Arthroplasty. J Bone Joint Surg Am 2019; 101:1713-1723. [PMID: 31577676 DOI: 10.2106/jbjs.18.01205] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Implant malalignment may predispose patients to prosthetic failure following total knee arthroplasty (TKA). A more thorough understanding of the surgeon-specific factors that contribute to implant malalignment following TKA may uncover actionable strategies for improving implant survival. The purpose of this study was to determine the impact of surgeon volume and training status on malalignment. METHODS In this retrospective multicenter study, we performed a radiographic analysis of 1,570 primary TKAs performed at 4 private academic and state-funded centers in the U.S. and U.K. Surgeons were categorized as high-volume (≥50 TKAs/year) or low-volume (<50 TKAs/year), and as a trainee (fellow/resident under the supervision of an attending surgeon) or a non-trainee (attending surgeon). On the basis of these designations, 3 groups were defined: high-volume non-trainee, low-volume non-trainee, and trainee. The postoperative medial distal femoral angle (DFA), medial proximal tibial angle (PTA), and posterior tibial slope angle (PSA) were radiographically measured. Outlier measurements were defined as follows: DFA, outside of 5° ± 3° of valgus; PTA, >±3° deviation from the neutral axis; and PSA, <0° or >7° of flexion for cruciate-retaining or <0° or >5° of flexion for posterior-stabilized TKAs. "Far outliers" were defined as measurements falling >± 2° outside of these ranges. The proportions of outliers were compared between the groups using univariate and multivariate analyses. RESULTS When comparing the high and low-volume non-trainee groups using univariate analysis, the proportions of knees with outlier measurements for the PTA (5.3% versus 17.4%) and PSA (17.4% versus 28.3%) and the proportion of total outliers (11.8% versus 20.7%) were significantly lower in the high-volume group (all p < 0.001). The proportions of DFA (1.9% versus 6.5%), PTA (1.8% versus 5.7%), PSA (5.5% versus 12.6%), and total far outliers (3.1% versus 8.3%) were also significantly lower in the high-volume non-trainee group (all p < 0.001). Compared with the trainee group, the high-volume non-trainee group had significantly lower proportions of DFA (12.6% versus 21.6%), PTA (5.3% versus 12.0%), PSA (17.4% versus 33.3%), and total outliers (11.8% versus 22.3%) (all p < 0.001) as well as DFA (1.9% versus 3.9%; p = 0.027), PSA (5.5% versus 12.6%; p < 0.001), and total far outliers (3.1% versus 6.4%; p = 0.004). No significant differences were identified when comparing the low-volume non-trainee group and the trainee group, with the exception of PTA outliers (17.4% versus 12.0%; p = 0.041) and PTA far outliers (5.7% versus 2.6%; p = 0.033). Findings from multivariate analysis accounting for the effects of patient age, body mass index, and individual surgeon demonstrated similar results. CONCLUSIONS Low surgical volume and trainee status were risk factors for outlier and far-outlier malalignment in primary TKA, even when accounting for differences in individual surgeon and patient characteristics. Trainee surgeons performed similarly, and certainly not inferiorly, to low-volume non-trainee surgeons. Even among high-volume non-trainees, the best-performing cohort in our study, the proportion of TKA alignment outliers was still high. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gregory S Kazarian
- Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Charles M Lawrie
- Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Toby N Barrack
- Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Matthew J Donaldson
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, United Kingdom.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, United Kingdom
| | - Gary M Miller
- Department of Orthopaedic Surgery, John Cochran Veterans Hospital-VA St. Louis Health Care System, St. Louis, Missouri
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, United Kingdom.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, United Kingdom
| | - Robert L Barrack
- Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
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Laende EK, Richardson CG, Dunbar MJ. A randomized controlled trial of tibial component migration with kinematic alignment using patient-specific instrumentation versus mechanical alignment using computer-assisted surgery in total knee arthroplasty. Bone Joint J 2019; 101-B:929-940. [PMID: 31362561 DOI: 10.1302/0301-620x.101b8.bjj-2018-0755.r3] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIMS Patient-specific instrumentation of total knee arthroplasty (TKA) is a technique permitting the targeting of individual kinematic alignment, but deviation from a neutral mechanical axis may have implications on implant fixation and therefore survivorship. The primary objective of this randomized controlled study was to compare the fixation of tibial components implanted with patient-specific instrumentation targeting kinematic alignment (KA+PSI) versus components placed using computer-assisted surgery targeting neutral mechanical alignment (MA+CAS). Tibial component migration measured by radiostereometric analysis was the primary outcome measure (compared longitudinally between groups and to published acceptable thresholds). Secondary outcome measures were inducible displacement after one year and patient-reported outcome measures (PROMS) over two years. The secondary objective was to assess the relationship between alignment and both tibial component migration and inducible displacement. PATIENTS AND METHODS A total of 47 patients due to undergo TKA were randomized to KA+PSI (n = 24) or MA+CAS (n = 23). In the KA+PSI group, there were 16 female and eight male patients with a mean age of 64 years (sd 8). In the MA+CAS group, there were 17 female and six male patients with a mean age of 63 years (sd 7). Surgery was performed using cemented, cruciate-retaining Triathlon total knees with patellar resurfacing, and patients were followed up for two years. The effect of alignment on tibial component migration and inducible displacement was analyzed irrespective of study group. RESULTS There was no difference over two years in longitudinal migration of the tibial component between the KA+PSI and MA+CAS groups (reaching median maximum total point motion migration at two years of 0.40 mm for the KA+PSI group and 0.37 mm for the MA+CAS group, p = 0.82; p = 0.68 adjusted for age, sex, and body mass index (BMI) for all follow-ups). Both groups had mean migrations below acceptable thresholds. There was no difference in inducible displacement (p = 0.34) or PROMS (p = 0.61 for the Oxford Knee Score) between groups. There was no correlation between alignment and tibial component migration or alignment and inducible displacement. These findings support non-neutral alignment as a viable option with this component, with no evidence that it compromises fixation. CONCLUSION Kinematic alignment using patient-specific instrumentation in TKA was associated with acceptable tibial component migration, indicating stable fixation. These results are supportive of future investigations of kinematic alignment. Cite this article: Bone Joint J 2019;101-B:929-940.
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Affiliation(s)
- E K Laende
- Department of Surgery, Dalhousie University, Halifax, Canada.,QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Canada
| | - C G Richardson
- Department of Surgery, Dalhousie University, Halifax, Canada.,QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Canada
| | - M J Dunbar
- Department of Surgery, Dalhousie University, Halifax, Canada.,QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Canada
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León-Muñoz VJ, Martínez-Martínez F, López-López M, Santonja-Medina F. Patient-specific instrumentation in total knee arthroplasty. Expert Rev Med Devices 2019; 16:555-567. [PMID: 31154870 DOI: 10.1080/17434440.2019.1627197] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is one of the most commonly performed orthopedic procedures. During the past decade, patient-specific instrumentation (PSI) has been commercially introduced in order to simplify and make TKA surgery more effective, precise and efficient than conventional mechanical instrumentation (CI) and computer-assisted surgery (CAS). Nevertheless, there are critical arguments against PSI for routine use. The aim of the current manuscript is to describe advantages and limitations of PSI for primary TKA. AREAS COVERED By means of a description of the available literature different aspects are discussed (accuracy, clinical and functional outcomes, operative time, blood loss, efficiency and costs). EXPERT OPINION Most publications do not claim a significant increase in PSI accuracy over CI, but they also do not postulate PSIs accuracy is worse either. Regarding clinical aspects, PSI did not appear to give any advantage over standard techniques although, equally, it did not appear to show any disadvantages. PSI seems to reduce operative time, could reduce perioperative blood loss and provides logistical benefits in the operation room. Further studies will be required to more thoroughly assess all the advantages and disadvantages of this promising technology as an alternative to CI and CAS.
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Affiliation(s)
- Vicente J León-Muñoz
- a Orthopaedic Surgery and Traumatology Department , Hospital Clínico Universitario Virgen de la Arrixaca , Murcia , Spain
| | - Francisco Martínez-Martínez
- a Orthopaedic Surgery and Traumatology Department , Hospital Clínico Universitario Virgen de la Arrixaca , Murcia , Spain.,b Faculty of Medicine , University of Murcia , Murcia , Spain
| | - Mirian López-López
- c Subdirección General de Tecnologías de la Información. Servicio Murciano de Salud , Murcia , Spain
| | - Fernando Santonja-Medina
- a Orthopaedic Surgery and Traumatology Department , Hospital Clínico Universitario Virgen de la Arrixaca , Murcia , Spain.,b Faculty of Medicine , University of Murcia , Murcia , Spain
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Teeter MG, Marsh JD, Howard JL, Yuan X, Vasarhelyi EM, McCalden RW, Naudie DDR. A randomized controlled trial investigating the value of patient-specific instrumentation for total knee arthroplasty in the Canadian healthcare system. Bone Joint J 2019; 101-B:565-572. [DOI: 10.1302/0301-620x.101b5.bjj-2018-1323.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The purpose of the present study was to compare patient-specific instrumentation (PSI) and conventional surgical instrumentation (CSI) for total knee arthroplasty (TKA) in terms of early implant migration, alignment, surgical resources, patient outcomes, and costs. Patients and Methods The study was a prospective, randomized controlled trial of 50 patients undergoing TKA. There were 25 patients in each of the PSI and CSI groups. There were 12 male patients in the PSI group and seven male patients in the CSI group. The patients had a mean age of 69.0 years (sd 8.4) in the PSI group and 69.4 years (sd 8.4) in the CSI group. All patients received the same TKA implant. Intraoperative surgical resources and any surgical waste generated were recorded. Patients underwent radiostereometric analysis (RSA) studies to measure femoral and tibial component migration over two years. Outcome measures were recorded pre- and postoperatively. Overall costs were calculated for each group. Results There were no differences (p > 0.05) in any measurement of migration at two years for either the tibial or femoral components. Movement between one and two years was < 0.2 mm, indicating stable fixation. There were no differences in coronal or sagittal alignment between the two groups. The PSI group took a mean 6.1 minutes longer (p = 0.04) and used a mean 3.4 less trays (p < 0.0001). Total waste generated was similar (10 kg) between the two groups. The PSI group cost a mean CAD$1787 more per case (p < 0.01). Conclusion RSA criteria suggest that both groups will have revision rates of approximately 3% at five years. The advantages of PSI were minimal or absent for surgical resources used and waste eliminated, and for meeting target alignment, yet had significantly greater costs. Therefore, we conclude that PSI may not offer any advantage over CSI for routine primary TKA cases. Cite this article: Bone Joint J 2019;101-B:565–572.
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Affiliation(s)
- M. G. Teeter
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Canada
- Department of Medical Biophysics, Schulich School of Medicine &Dentistry, Western University, London, Canada
- Surgical Innovation Program, Lawson Health Research Institute, London, Canada
- Imaging Research Laboratories, Robarts Research Institute, London, Canada
- Bone and Joint Institute, Western University, London, Canada
| | - J. D. Marsh
- Bone and Joint Institute, Western University, London, Canada
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, Canada
| | - J. L. Howard
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Canada
| | - X. Yuan
- Imaging Research Laboratories, Robarts Research Institute, London, Canada
| | - E. M. Vasarhelyi
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Canada
| | - R. W. McCalden
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Canada
| | - D. D. R. Naudie
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Canada
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McAuliffe MJ, Beer BR, Hatch JJ, Crawford RW, Cuthbert AR, Donnelly WJ. Impact of Image-Derived Instrumentation on Total Knee Arthroplasty Revision Rates: An Analysis of 83,823 Procedures from the Australian Orthopaedic Association National Joint Replacement Registry. J Bone Joint Surg Am 2019; 101:580-588. [PMID: 30946191 DOI: 10.2106/jbjs.18.00326] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Computer navigation and image-derived instrumentation (IDI) are technology-based methods developed to improve outcomes and potentially reduce revision total knee arthroplasty (TKA). IDI refers to the use of manufactured, patient-specific surgical jigs. Conflicting reports exist on IDI-associated improvements in outcomes. The primary aim of the current study was to compare the rates of revision among TKA cases in which components were initially implanted with use of IDI, computer navigation, or neither of these methods ("other" TKA). The secondary aim was to determine whether the outcomes of IDI differed for specific subgroups. METHODS Data were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) for the 3 TKA groups: IDI, computer-navigated, and other TKA. The study period was from the first IDI procedure recorded by the AOANJRR (April 2010) to December 31, 2016. The analysis was restricted to primary TKA cases undertaken for osteoarthritis and involving patellar resurfacing and the use of a cross-linked polyethylene insert. Subanalyses were performed to evaluate the effects of age, sex, implantation method, IDI manufacturer, prosthetic design, and prosthesis type on the rates of revision. Kaplan-Meier estimates of survivorship described the time to first revision. Hazard ratios (HRs, Cox proportional hazards models) with adjustment for age and sex were used to compare revision rates. RESULTS IDI was used in 5,486 primary TKA procedures. There was no significant difference among the groups in the cumulative percent revision (CPR) at 5 years: 3.3% (95% confidence interval [CI], 2.4% to 4.6%) for IDI, 2.4% (95% CI, 2.2% to 2.7%) for the computer-navigated group, and 2.5% (95% CI, 2.3% to 2.7%) for other TKA. Posterior-stabilized TKA with use of the IDI method had a significantly higher rate of revision at >3 months (HR, 1.45 [95% CI, 1.02 to 2.04]; p = 0.036), as did IDI TKA in the ≤65-year-old patient cohort (HR, 1.52 [95% CI, 1.10 to 2.09]; p = 0.010), compared with computer-navigated TKA. Patellar revision was significantly more likely in the IDI group. CONCLUSIONS IDI TKA demonstrated no overall difference in early to mid-term revision rates compared with standard implantation methods. However, elevated rates of revision were seen with posterior-stabilized TKA, in patients ≤65 years of age, and for patellar revision, meaning that this method should be used with some caution and requires further study. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael J McAuliffe
- Department of Orthopaedics, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Benjamin R Beer
- Department of Orthopaedics, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Joshua J Hatch
- Department of Orthopaedics, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Ross W Crawford
- Queensland University of Technology, Brisbane City, Queensland, Australia
| | - Alana R Cuthbert
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - William J Donnelly
- Department of Orthopaedics, Prince Charles Hospital, Chermside, Queensland, Australia
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Gong S, Xu W, Wang R, Wang Z, Wang B, Han L, Chen G. Patient-specific instrumentation improved axial alignment of the femoral component, operative time and perioperative blood loss after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27:1083-1095. [PMID: 30377714 PMCID: PMC6435625 DOI: 10.1007/s00167-018-5256-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/19/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of the present study was to compare patient-specific instrumentation (PSI) with standard instrumentation (SI) in patients undergoing total knee arthroplasty (TKA). PSI is hypothesized to have advantages with respect to component alignment; number of outliers (defined as alignment > 3° from the target alignment); operative time; perioperative blood loss; and length of hospital stay. This new surgical technique is expected to exhibit superior performance. METHODS A total of 23 randomized controlled trials (RCTs) involving 2058 knees that compared the clinical outcomes of TKA between PSI and SI were included in the present analysis; these RCTs were identified via a literature search of the PubMed, Embase, and Cochrane Library databases through March 1, 2018. The outcomes of interest included coronal, sagittal and axial component alignment (presented as the angle of deviation from the transcondylar line); number of outliers; operative time; perioperative blood loss; and length of hospital stay. RESULTS There was a significant difference in postoperative femoral axial alignment between PSI and SI patients (95% CI - 0.71 to - 0.21, p = 0.0004, I2 = 48%). PSI resulted in approximately 0.4° less deviation from the transcondylar line than SI. Based on our results, PSI reduced operative time by a mean of 7 min compared with SI (95% CI - 10.95 to - 3.75, p < 0.0001, I2 = 78%). According to the included literature, PSI reduced perioperative blood loss by approximately 90 ml compared with SI (95% CI - 146.65 to - 20.18, p = 0.01, I2 = 74%). We did not find any differences between PSI and SI with respect to any other parameters. CONCLUSIONS PSI has advantages in axial alignment of the femoral component, operative time, and perioperative blood loss relative to SI. No significant differences were found between PSI and SI with respect to alignment of the remaining components, number of outliers, or length of hospital stay. LEVEL OF EVIDENCE Therapeutic study (systematic review and meta-analysis), Level I.
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Affiliation(s)
- Song Gong
- 0000 0004 0368 7223grid.33199.31Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Weihua Xu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Ruoyu Wang
- 0000 0004 0368 7223grid.33199.31Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Zijian Wang
- 0000 0004 0368 7223grid.33199.31Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Bo Wang
- 0000 0004 0368 7223grid.33199.31Department of Rehabilitation, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Lizhi Han
- 0000 0004 0368 7223grid.33199.31Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Guo Chen
- 0000 0004 0368 7223grid.33199.31Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
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18
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Arbab D, Reimann P, Brucker M, Bouillon B, Lüring C. Alignment in total knee arthroplasty - A comparison of patient-specific implants with the conventional technique. Knee 2018; 25:882-887. [PMID: 29936030 DOI: 10.1016/j.knee.2018.05.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 05/10/2018] [Accepted: 05/24/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Incorrect positioning and malalignment of total knee arthroplasty (TKA) components can result in implant loosening. Restoration of neutral alignment of the leg is an important factor affecting the long-term results of TKA. The aim of our retrospective study was to compare mechanical axis in patients with conventional and patient-specific TKAs. METHODS 232 patients who underwent TKA between January 2013 and December 2014 were included to compare postoperative mechanical axis. 125 patients received a patient-specific TKA (iTotal CR®, Conformis) and 107 a conventional TKA (Triathlon®, Stryker). Standardized pre- and postoperative long-leg standing radiographs were retrospectively evaluated to compare the two patient cohorts. RESULTS 113 (90%) radiographs of patient-specific TKA and 88 (82%) of conventional TKA were available for comparison. The preoperative deviation from neutral limb axis was 9.0° (0.1–27.3°) in the patient-specific TKA cohort and 8.2° (0.2–18.2°) in the conventional TKA group. Postoperatively the patient-specific TKA group showed 3.2° (0.1–8.4°) and the conventional TKA cohort 2.3° (0.1–12.5°) deviation. However, the rate of ± 3° outliers from neutral limb axis was 16% in the patient-specific TKA cohort and 26% in the conventional TKA group. CONCLUSIONS Patient-specific TKA demonstrated fewer outliers from neutral leg alignment compared to conventional technique. Potential benefits in the long-term outcome and functional improvement require further investigation.
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Affiliation(s)
- Dariusch Arbab
- Department of Orthopedic Surgery, Klinikum Dortmund, Member Faculty of Health Witten/Herdecke University, Beurhausstraße 40, 44137 Dortmund, Germany.
| | - Pia Reimann
- Ruhr University Bochum, Universitätsstraße 150, 44801 Bochum, Germany
| | - Martin Brucker
- Department of Orthopedic Surgery, Klinikum Dortmund, Beurhausstraße 40, 44137 Dortmund, Germany
| | - Bertil Bouillon
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany.
| | - Christian Lüring
- Department of Orthopedic Surgery, Klinikum Dortmund, Beurhausstraße 40, 44137 Dortmund, Germany.
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Schotanus MGM, Thijs E, Heijmans M, Vos R, Kort NP. Favourable alignment outcomes with MRI-based patient-specific instruments in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2018; 26:2659-2668. [PMID: 28698929 DOI: 10.1007/s00167-017-4637-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/06/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE Patient-specific instruments (PSIs) are already in relatively common use, and their post-operative radiographic results are equal to those for total knee arthroplasty (TKA) with conventional instrumentation. PSI use requires a preoperative MRI scan, CT scan, or a combination of MRI and a long-leg standing radiograph. However, there is no consensus as to which of these modalities, MRI or CT, is the preferred imaging modality when performing TKA with PSIs. METHODS This systematic literature review and meta-analysis studied the differences in alignment outliers between CT- and MRI-based PSI for TKA. A search of the Cochrane Database of Systematic Reviews, MEDLINE/PubMed and Embase was conducted, without restriction on date of publication. Only level I evidence studies written in English that included TKA with the use of MRI- and CT-based PSI were selected. A meta-analysis was then performed of the rate of outliers in the biomechanical axis and individual femoral and tibial component alignment. Where considerable heterogeneity among studies was present or the data did not provide sufficient information for performing the meta-analysis, a qualitative synthesis was undertaken. RESULTS Twelve randomized controlled trials, studying 841 knees, were eligible for data extraction and meta-analysis. MRI-based PSI resulted in a significantly lower proportion of coronal plane outliers with regard to the lateral femoral component (OR 0.52, 95% CI 0.30-0.89, P = 0.02), without significant heterogeneity (n.s.). There were no significant differences regarding the biomechanical axis or frontal femoral and individual tibial component alignment. CONCLUSION This systematic review and meta-analysis demonstrate that alignment with MRI-based PSI is at least as good as, if not better than, that with CT-based PSI. To prevent for malalignment, MRI should be the imaging modality of choice when performing TKA surgery with PSI. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Martijn G M Schotanus
- Zuyderland Medical Centre, Dr H vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands.
| | - Elke Thijs
- Zuyderland Medical Centre, Dr H vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
| | - Marion Heijmans
- Zuyderland Academy, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Rein Vos
- Department of Methodology and Statistics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nanne P Kort
- Zuyderland Medical Centre, Dr H vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
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Gao T, Rivlin M, Abraham JA. Three-dimensional Printing Technology and Role for Custom Implants in Orthopedic Oncology. Tech Orthop 2018. [DOI: 10.1097/bto.0000000000000292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Papagelopoulos PJ, Savvidou OD, Koutsouradis P, Chloros GD, Bolia IK, Sakellariou VI, Kontogeorgakos VA, Mavrodontis II, Mavrogenis AF, Diamantopoulos P. Three-dimensional Technologies in Orthopedics. Orthopedics 2018; 41:12-20. [PMID: 29401368 DOI: 10.3928/01477447-20180109-04] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
New 3-dimensional digital technologies are revolutionizing orthopedic clinical practice, allowing structures of any complexity to be manufactured in just hours. Such technologies can make surgery for complex cases more precise, more cost-effective, and possibly easier to perform. Applications include pre-operative planning, surgical simulation, patient-specific instrumentation and implants, bioprinting, prosthetics, and orthotics. The basic principles of 3- dimensional technologies, including imaging, design, numerical simulation, and printing, and their current applications in orthopedics are reviewed. [Orthopedics. 2018; 41(1):12-20.].
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Chughtai M, Khlopas A, Davidson IU, Yakubek GA, Stearns KL, Mont MA. Custom cutting guides in total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:216. [PMID: 28603731 DOI: 10.21037/atm.2017.02.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Iyooh U Davidson
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - George A Yakubek
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kim L Stearns
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Haglin JM, Eltorai AEM, Gil JA, Marcaccio SE, Botero-Hincapie J, Daniels AH. Patient-Specific Orthopaedic Implants. Orthop Surg 2017; 8:417-424. [PMID: 28032697 DOI: 10.1111/os.12282] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/13/2016] [Indexed: 12/19/2022] Open
Abstract
Patient-specific orthopaedic implants are emerging as a clinically promising treatment option for a growing number of conditions to better match an individual's anatomy. Patient-specific implant (PSI) technology aims to reduce overall procedural costs, minimize surgical time, and maximize patient outcomes by achieving better biomechanical implant fit. With this commercially-available technology, computed tomography or magnetic resonance images can be used in conjunction with specialized computer programs to create preoperative patient-specific surgical plans and to develop custom cutting guides from 3-D reconstructed images of patient anatomy. Surgeons can then place these temporary guides or "jigs" during the procedure, allowing them to better recreate the exact resections of the computer-generated surgical plan. Over the past decade, patient-specific implants have seen increased use in orthopaedics and they have been widely indicated in total knee arthroplasty, total hip arthroplasty, and corrective osteotomies. Patient-specific implants have also been explored for use in total shoulder arthroplasty and spinal surgery. Despite their increasing popularity, significant support for PSI use in orthopaedics has been lacking in the literature and it is currently uncertain whether the theoretical biomechanical advantages of patient-specific orthopaedic implants carry true advantages in surgical outcomes when compared to standard procedures. The purpose of this review was to assess the current status of patient-specific orthopaedic implants, to explore their future direction, and to summarize any comparative published studies that measure definitive surgical characteristics of patient-specific orthopaedic implant use such as patient outcomes, biomechanical implant alignment, surgical cost, patient blood loss, or patient recovery.
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Affiliation(s)
| | - Adam E M Eltorai
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Joseph A Gil
- Division of Spine Surgery, Department of Orthopaedic Surgery, Providence, Rhode Island, USA.,Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Stephen E Marcaccio
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Alan H Daniels
- Division of Spine Surgery, Department of Orthopaedic Surgery, Providence, Rhode Island, USA.,Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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24
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Thienpont E, Schwab PE, Fennema P. Efficacy of Patient-Specific Instruments in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2017; 99:521-530. [PMID: 28291186 DOI: 10.2106/jbjs.16.00496] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patient-specific instrumentation (PSI) was introduced with the aim of making the procedure of total knee arthroplasty more accurate and efficient. The purpose of this study was to compare PSI and standard instrumentation in total knee arthroplasty with regard to radiographic and clinical outcomes as well as operative time and blood loss. METHODS A meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. PubMed and Embase were searched from 2011 through 2015. We included randomized controlled trials and cohort studies that reported the effect of PSI on the aforementioned outcomes. The primary end point was deviation from the mechanical axis by >3°. Random and fixed-effect models were used for analysis. RESULTS A total of 44 studies, which included 2,866 knees that underwent surgery with PSI and 2,956 knees that underwent surgery with standard instrumentation, were evaluated. The risk of mechanical axis malalignment was significantly lower for PSI, with a pooled relative risk of 0.79 (p = 0.013). The risk of tibial sagittal-plane malalignment was higher for PSI than for standard instrumentation (relative risk = 1.32, p = 0.001), whereas the risk of femoral coronal-plane malalignment was significantly lower (relative risk = 0.74, p = 0.043). The risk of tibial coronal-plane malalignment was significantly higher for PSI only when employing fixed-effect meta-analysis (relative risk = 1.33, p = 0.042). Minor reductions in total operative time (-4.4 minutes, p = 0.002) and blood loss (-37.9 mL, p = 0.015) were noted for PSI. CONCLUSIONS PSI improves the accuracy of femoral component alignment and global mechanical alignment, but at the cost of an increased risk of outliers for the tibial component alignment. The impact of the increased probability of tibial component malalignment on implant longevity remains to be determined. Meta-analyses indicated significant differences with regard to operative time and blood loss in favor of PSI. However, these differences were minimal and, by themselves, not a substantial justification for routine use of the technology. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Emmanuel Thienpont
- 1University Hospital Saint Luc, Brussels, Belgium 2AMR Advanced Medical Research, Männedorf, Switzerland
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The Chitranjan S. Ranawat Award : No Difference in 2-year Functional Outcomes Using Kinematic versus Mechanical Alignment in TKA: A Randomized Controlled Clinical Trial. Clin Orthop Relat Res 2017; 475:9-20. [PMID: 27113595 PMCID: PMC5174030 DOI: 10.1007/s11999-016-4844-x] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Neutral mechanical alignment (MA) in total knee arthroplasty (TKA) aims to position femoral and tibial components perpendicular to the mechanical axis of the limb. In contrast, kinematic alignment (KA) attempts to match implant position to the prearthritic anatomy of the individual patient with the aim of improving functional outcome. However, comparative data between the two techniques are lacking. QUESTIONS/PURPOSES In this randomized trial, we asked: (1) Are 2-year patient-reported outcome scores enhanced in patients with KA compared with an MA technique? (2) How does postoperative component alignment differ between the techniques? (3) Is the proportion of patients undergoing reoperation at 2 years different between the techniques? METHODS Ninety-nine primary TKAs in 95 patients were randomized to either MA (n = 50) or KA (n = 49) groups. A pilot study of 20 TKAs was performed before this trial using the same patient-specific guides positioning in kinematic alignment. In the KA group, patient-specific cutting blocks were manufactured using individual preoperative MRI data. In the MA group, computer navigation was used to ensure neutral mechanical alignment accuracy. Postoperative alignment was assessed with CT scan, and functional scores (including the Oxford Knee Score, WOMAC, and the Forgotten Joint Score) were assessed preoperatively and at 6 weeks, 6 months, and 1 and 2 years postoperatively. No patients were lost to followup. We set sample size at a minimum of 45 patients per treatment arm based on a 5-point improvement in the mean Oxford Knee Score (OKS; the previously reported minimum clinically significant difference for the OKS in TKA), a pooled SD of 8.3, 80% power, and a two-sided significance level of 5%. RESULTS We observed no difference in 2-year change scores (postoperative minus preoperative score) in KA versus MA patients for the OKS (mean 21, SD 8 versus 20, SD 8, least square means 1.0, 95% confidence interval [CI], -1.4 to 3.4, p = 0.4), WOMAC score (mean 38, SD 18 versus 35, SD 8, least square means 3, 95% CI, -3.2 to 8.9, p = 0.3), or Forgotten Joint score (28 SD 37 versus 28, SD 28, least square means 0.8, 95% CI, -9.1-10.7, p = 0.8). Postoperative hip-knee-ankle axis was not different between groups (mean KA 0.4° varus SD 3.5 versus MA 0.7° varus SD 2.0), but in the KA group, the tibial component was a mean 1.9° more varus than the MA group (95% CI, 0.8°-3.0°, p = 0.003) and the femoral component in 1.6° more valgus (95% CI, -2.5° to -0.7°, p = 0.003). Complication rates were not different between groups. CONCLUSIONS We found no difference in 2-year patient-reported outcome scores in TKAs implanted using the KA versus an MA technique. The theoretical advantages of improved pain and function that form the basis of the design rationale of KA were not observed in this study. Currently, it is unknown whether the alterations in component alignment seen with KA will compromise long-term survivorship of TKA. In this study, we were unable to demonstrate an advantage to KA in terms of pain or function that would justify this risk. LEVEL OF EVIDENCE Level I, therapeutic study.
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Failure at the Tibial Cement-Implant Interface With the Use of High-Viscosity Cement in Total Knee Arthroplasty. J Arthroplasty 2016; 31:2579-2582. [PMID: 27155996 DOI: 10.1016/j.arth.2016.03.063] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 03/11/2016] [Accepted: 03/29/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Recent literature has shown debonding of the tibial implant-cement interface as a potential cause for implant loosening. The purpose of this case series is to report this phenomenon in a historically well-performing implant when used with high-viscosity cement (HVC). METHODS Thirteen primary cemented Biomet Vanguard total knee arthroplasties were referred to 1 of 2 institutions with complaints of persistent pain after their index procedure. A radiographic and infectious work-up was completed for each patient. All 13 patients underwent a revision of the index surgery with intraoperative diagnosis of tibial component debonding at the implant-cement interface. HVC (Cobalt, DJO Surgical, Vista, CA and Depuy HVC; Depuy Inc, Warsaw, IN) was used in all index cases. RESULTS The average time to revision surgery for the 13 patients was 2.7 ± 1.9 years from the index surgery. Laboratory infectious markers were within normal in most cases, and all intra-articular aspirations showed no bacterial, fungal, or anaerobic growth. Eleven of 13 patients showed no radiographic evidence of loosening; however, all cases demonstrated tibial component debonding intraoperatively. CONCLUSION Given our institution's experience and previously reported data demonstrating excellent survivorship with this total knee arthroplasty prosthesis, we propose that the early failures seen in this case series may be associated with the use of HVC cement. In the setting of a negative infectious work-up and no radiographic evidence to suggest loosening, the surgeon should consider debonding of the tibial component as a potential cause for persistent pain if HVC cement was used with this prosthetic design.
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Tack P, Victor J, Gemmel P, Annemans L. 3D-printing techniques in a medical setting: a systematic literature review. Biomed Eng Online 2016; 15:115. [PMID: 27769304 PMCID: PMC5073919 DOI: 10.1186/s12938-016-0236-4] [Citation(s) in RCA: 535] [Impact Index Per Article: 66.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 10/09/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Three-dimensional (3D) printing has numerous applications and has gained much interest in the medical world. The constantly improving quality of 3D-printing applications has contributed to their increased use on patients. This paper summarizes the literature on surgical 3D-printing applications used on patients, with a focus on reported clinical and economic outcomes. METHODS Three major literature databases were screened for case series (more than three cases described in the same study) and trials of surgical applications of 3D printing in humans. RESULTS 227 surgical papers were analyzed and summarized using an evidence table. The papers described the use of 3D printing for surgical guides, anatomical models, and custom implants. 3D printing is used in multiple surgical domains, such as orthopedics, maxillofacial surgery, cranial surgery, and spinal surgery. In general, the advantages of 3D-printed parts are said to include reduced surgical time, improved medical outcome, and decreased radiation exposure. The costs of printing and additional scans generally increase the overall cost of the procedure. CONCLUSION 3D printing is well integrated in surgical practice and research. Applications vary from anatomical models mainly intended for surgical planning to surgical guides and implants. Our research suggests that there are several advantages to 3D-printed applications, but that further research is needed to determine whether the increased intervention costs can be balanced with the observable advantages of this new technology. There is a need for a formal cost-effectiveness analysis.
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Affiliation(s)
- Philip Tack
- Department of Public Health, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Jan Victor
- Ghent University Hospital, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - Paul Gemmel
- Departement of Economics & Business Administration, Ghent University, Tweekerkenstraat 2, 9000, Ghent, Belgium
| | - Lieven Annemans
- Department of Public Health, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
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Nam D, Vajapey S, Nunley RM, Barrack RL. The Impact of Imaging Modality on the Measurement of Coronal Plane Alignment After Total Knee Arthroplasty. J Arthroplasty 2016; 31:2314-9. [PMID: 27067164 DOI: 10.1016/j.arth.2016.02.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/16/2016] [Accepted: 02/27/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The optimal coronal alignment after total knee arthroplasty (TKA) has become an area of increased debate. Sources of variability among investigations include the radiographic technique used for both preoperative surgical planning and postoperative alignment assessments. This study's purpose was to assess the impact of the imaging modality used on the measurement of coronal plane alignment after TKA. METHODS A consecutive series of patients undergoing TKA using the same cruciate-retaining prosthesis were included for analysis. Postoperatively, all patients received both a rotationally controlled, scout computed tomography scan and a hip-knee-ankle (HKA) image using the EOS Imaging system (EOS Inc., Paris, France). Two, independent observers measured the HKA angle, and femoral and tibial component alignment from each image. RESULTS After classifying overall and component alignment as neutral, varus, or valgus, 40.6% (65 of 160) of knees had a discordant alignment classification for HKA, 28.1% (45 of 160) for femoral component alignment, and 26.9% (43 of 160) for tibial component alignment between their computed tomography and EOS images. Overall, 24.4% (39 of 160) of patients had a HKA difference of ≥3° between the 2 images, whereas 18.8% (30 of 160) and 20.0% (32 of 160) of patients had a femoral and tibial component alignment difference of ≥2°, respectively. CONCLUSION Significant differences are present when comparing 2 measurement techniques of mechanical alignment after TKA. The impact of imaging modality on postoperative assessments must be accounted for and be consistent when comparing the results of different investigations.
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Affiliation(s)
- Denis Nam
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sravya Vajapey
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Robert L Barrack
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
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Handheld Navigation Device and Patient-Specific Cutting Guides Result in Similar Coronal Alignment for Primary Total Knee Arthroplasty: a Retrospective Matched Cohort Study. HSS J 2016; 12:224-234. [PMID: 27703415 PMCID: PMC5026651 DOI: 10.1007/s11420-015-9484-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 12/01/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Proper alignment of total knee arthroplasty (TKA) is essential for TKA function and may reduce the risk of aseptic failure. Technologies that prevent malalignment may reduce the risk of revision surgery. QUESTIONS/PURPOSES The purpose of this study was to compare two competing TKA systems that purport improved alignment: patient-specific instrumentation (PSI), and a handheld portable navigation device (NAV). METHODS After IRB approval, 49 consecutive PSI TKAs (40 patients) were matched based on preoperative characteristics to 49 NAV TKAs (40 patients) performed by a single surgeon. A blinded observer measured alignment on digital radiographs. Operating room records were reviewed for procedure times. Two-tailed paired sample t tests and McNemar's test were used as appropriate. Alpha level was 0.05 for all tests. RESULTS Preoperative cohort characteristics were not different. Mean postoperative long-leg mechanical alignment was within ±1° of neutral for both groups, although statistically different (p = 0.026). There were no other significant differences in coronal alignment. PSI exhibited significantly greater posterior tibial slope (4.4°) compared to NAV (2.7°) (p = 0.004); PSI resulted in significantly more outliers (>6°; p = 0.004). Procedure time for unilateral TKAs was lower for PSI (74.4 min) compared to that for NAV (80.6 min; p = 0.023). CONCLUSION NAV and PSI technologies provided excellent coronal plane alignment. NAV was better for sagittal tibial slope, while PSI procedure times were shorter for unilateral TKA. The impact of these technologies on patient-reported outcomes and TKA survivorship is controversial and should be the focus of future research.
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Nam D, Berend ME, Nunley RM, Della Valle CJ, Berend KR, Lombardi AV, Barrack RL. Residual Symptoms and Function After Unicompartmental and Total Knee Arthroplasty: Comparable to Normative Controls? J Arthroplasty 2016; 31:2161-6. [PMID: 27067170 DOI: 10.1016/j.arth.2016.02.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 02/23/2016] [Accepted: 02/27/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Whether patient-reported symptoms and function after total knee arthroplasty (TKA) and medial unicompartmental knee arthroplasty (UKA) compare favorably to similar individuals without a diagnosis of knee pathology has not been investigated. METHODS A retrospective, multicenter study was designed in which 4 centers contributed patients between ages 18 and 80 years undergoing knee arthroplasty. Data were collected by an independent, third-party survey center that administered a questionnaire assessing patient satisfaction and function. The survey center identified a "control" population of the same age range using a "random digit dial call method" with no prior knee interventions or major problems with their knees limiting their activity. Comparisons were performed using multivariate logistic regression analyses accounting for differences in demographic variables among the 3 cohorts. RESULTS Overall, 1456 TKAs, 476UKAs, and 409 controls were included for analysis. Controls reported a surprisingly high incidence of pain (30%), a limp (26%), stiffness (22%), and noise (21%) in their knee. However, the likelihood of reported noise (odds ratio [OR], 1.3), swelling (OR, 1.4), stiffness (OR, 1.8), and difficulty getting in and out of a chair (OR, 2.5) was increased after TKA vs controls (P < .001-.03). The likelihood of swelling (OR, 1.8), stiffness (OR, 1.5), and difficulty getting in and out of a chair (OR, 1.7) was increased after UKA vs controls (P = .002-.005). CONCLUSION When interviewed by an independent, third party, a substantial percentage of control patients reported the presence of knee symptoms, but to a lesser degree than patients after a knee arthroplasty.
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Affiliation(s)
- Denis Nam
- Department of Orthopedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Michael E Berend
- The Center for Hip and Knee Surgery, St. Francis Hospital, Mooresville, Indiana
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | | | | | - Robert L Barrack
- Department of Orthopedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
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Boettner F, Renner L, Arana Narbarte D, Egidy C, Faschingbauer M. Total knee arthroplasty for valgus osteoarthritis: the results of a standardized soft-tissue release technique. Knee Surg Sports Traumatol Arthrosc 2016; 24:2525-31. [PMID: 26939552 DOI: 10.1007/s00167-016-4054-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/09/2016] [Indexed: 01/13/2023]
Abstract
PURPOSE The study reports the 2-year follow-up results of patients with valgus osteoarthritis undergoing total knee arthroplasty (TKA) with a standardized soft-tissue release. METHODS Between 2008 and 2013, 222 TKAs were performed for valgus osteoarthritis by a single surgeon. A total of 181 TKAs in 164 patients were available for a minimum 2-year follow-up (range 24-87 months). Preoperative and postoperative range of motion (ROM), mechanical alignment, the postoperative medial proximal tibial angle (MPTA), Western Ontario and McMaster Universities Arthritis Index (WOMAC), VF-12 score, visual analogue pain scale (VAS), and the actual UCLA activity score, desired UCLA score, ligamentous stability (medial collateral ligament) and complications and revision rates were recorded. RESULTS The ROM increased from a preoperative flexion contracture of 4.7° (range 0-40) and flexion of 110° (range 35-135) to a postoperative mean flexion contracture of 0.1° (range -5 to 10) and flexion of 128° (range 100-140). The mean hip-knee-ankle alignment was changed from 8.4° of mechanical valgus (range 5.3-25.4) to 0.02° of varus alignment (range -2.9 to 4.1). Tibia component angle (MPTA) was 90.4° (range 86.1-93.7). The WOMAC score, VF-12, UCLA and VAS significantly improved after surgery (p < 0.05). Two patients (1.1 %) underwent revision surgery for instability. CONCLUSION The described standardized soft-tissue release (release of the iliotibial band and posterolateral corner) provided excellent clinical results at a minimum 2-year follow-up and can be used safely for a "cook-book" approach to the valgus knee with up to 25° mechanical valgus alignment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Lisa Renner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.,Department of Orthopedic Surgery, Center for Musculosceletal Surgery, Charite Universitaetsmedizin, Chariteplatz 1, 10117, Berlin, Germany
| | - Danik Arana Narbarte
- Hospital Galdakao-Usansolo, Servicio de Cirugia Ortopedica y Traumatologia, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain
| | - Claus Egidy
- Department of Orthopedics and Traumatology, Kantonsspital St. Gallen, Sankt Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Martin Faschingbauer
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.,Department for Orthopedics and Orthopedic Surgery, University of Ulm, 89081, Ulm, Germany
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Tomita T. Commentary: Clinical benefits of patientmatched instrumentation for total knee arthroplasty. J Orthop Surg (Hong Kong) 2016; 24:145. [PMID: 27574250 DOI: 10.1177/1602400203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- T Tomita
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, Osaka, Japan
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Chan WC, Pinder E, Loeffler M. Patient-specific instrumentation versus conventional instrumentation in total knee arthroplasty. J Orthop Surg (Hong Kong) 2016; 24:175-8. [PMID: 27574258 DOI: 10.1177/1602400211] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To compare patient-specific instrumentation (PSI) with conventional instrumentation in total knee arthroplasty (TKA) in terms of component alignment, operating time, and the learning curve required in a non-teaching hospital. METHODS Records of 33 men and 29 women aged 50 to 88 (mean, 71) years who underwent TKA for osteoarthritis using PSI (n=31) or conventional instrumentation (n=31) by a single surgeon were reviewed. The choice of instrumentation was made by the patient; the surgeon did not express any preference and had not used PSI before. All patients used the same cemented, cruciate-retaining system. RESULTS The PSI and conventional instrumentation groups were comparable in terms of age, body mass index (BMI), American Society of Anesthesiologists grade, pre- and post-operative haemoglobin level, and the need for blood transfusion. Compared with conventional instrumentation, PSI resulted in a smaller coronal femoral component angle (7.7º vs. 6.4º, p=0.003) and posterior tibial slope angle (6.4º vs. 3.2º, p=0.0001), and smaller variance of the respective angles (p=0.006 and p=0.003). In patients with a BMI ≥30, PSI still resulted in a smaller posterior tibial slope angle (5.8º vs. 3.1º, p=0.015) and variance of the angle (p=0.02). The mean tourniquet time was shorter in the PSI group in all patients (p=0.013) and in patients with BMI ≥30 kg/m2 (p=0.0008), and its variance was also smaller in the PSI group (p=0.0004). There was no learning curve required. CONCLUSION PSI was simple to use, with no learning curve required. It can be used in non-teaching hospitals and in patients with a high BMI and in cases where the use of an intramedullary alignment guide would be problematic due to previous femoral trauma.
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Affiliation(s)
- W Cw Chan
- Department of Trauma and Orthopaedics, Colchester Hospital University NHS Foundation Trust, Colchester, United Kingdom
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Abstract
Total knee arthroplasty has been an effective treatment for advanced degenerative joint disease. Traditional knee designs and surgical approaches have resulted in consistently high performance, but some patients may remain dissatisfied after their surgery. Several surgical innovations, including accelerometer-based navigation, patient-specific instrumentation, and robotic-assisted total knee arthroplasty, have been developed to improve the accuracy and precision of total knee arthroplasty surgery, with anticipated secondary benefits of improved functional outcomes and implant survivorship. This article reviews the current status of these technologies as reported in contemporary orthopedic literature. [Orthopedics. 2016; 39(4):217-220.].
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Abstract
Patient specific instrumentation (PSI) uses advanced imaging of the knee (CT or MRI) to generate individualised cutting blocks aimed to make the procedure of total knee arthroplasty (TKA) more accurate and efficient. However, in this era of healthcare cost consciousness, the value of new technologies needs to be critically evaluated. There have been several comparative studies looking at PSI versus standard instrumentation. Most compare PSI with conventional instrumentation in terms of alignment in the coronal plane, operative time and surgical efficiency, cost effectiveness and short-term outcomes. Several systematic reviews and meta-analyses have also been published. PSI has not been shown to be superior compared with conventional instrumentation in its ability to restore traditional mechanical alignment in primary TKA. Most studies show comparative efficacy and no decrease in the number of outliers in either group. In terms of operative time and efficiency, PSI tended towards decreasing operative time, saving a mean of five minutes per patient (0 to 20). Furthermore, while some cost savings could be realised with less operative time and reduced instrumentation per patient, these savings were overcome by the cost of the CT/MRI and the cutting blocks. Finally, there was no evidence that PSI positively affected clinical outcomes at two days, two months, or two years. Consequently, current evidence does not support routine use of PSI in routine primary TKA.
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Affiliation(s)
- G-C Lee
- University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
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Mattei L, Pellegrino P, Calò M, Bistolfi A, Castoldi F. Patient specific instrumentation in total knee arthroplasty: a state of the art. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:126. [PMID: 27162776 DOI: 10.21037/atm.2016.03.33] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Patient specific instrumentation (PSI) is a modern technique in total knee arthroplasty (TKA) aiming to facilitate the implant of the prosthesis. The customized cutting blocks of the PSI are generated from pre-operative three-dimensional model, using computed tomography (CT) or magnetic resonance imaging (MRI). A correct surgical plan is mandatory for a good surgical implant. The PSI guide takes into account any slight deformities or osteophytes and applies preoperative planning for bone resection, using the pre-determined implant size, position, and rotation. The apparent benefits of this technology are that neutral postoperative alignment is more reproducible, surgical time is decreased, and the entire procedure results more efficient and cost-effective. The use of PSI is indicated when advanced osteoarthritis, severe pain, and limited function/walking ability are present, such as in a standard instrumentation TKA. In addition to that, PSI finds its indication when intra-medullary guides cannot be used. For example, when there is a post-traumatic femoral deformity. Large debates have taken place about this topic during the last years and, at the moment, there is no consensus in literature regarding the accuracy and reliability of PSI as many studies have shown controversial and inconsistent results. Literature does not suggest PSI techniques as a gold standard in TKA, and therefore it cannot be recommended as a standard technique in standard, not complicated primary TKA. Moreover, literature does not underline any improvement in components alignment, surgical time, blood loss or functional outcomes. Nevertheless, many patients who underwent TKA suffered a previous trauma. In case of deformities, like femoral or tibial fractures healed with a malalignment, preoperative planning may result difficult, and some intra-operative technical difficulties can occur, such as the use of intra-medullar rod. In these selected cases, PSIs may be very useful to avoid errors in alignment and planning.
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Affiliation(s)
- Lorenzo Mattei
- CTO Hospital, Città della salute e della Scienza, Turin, Italy
| | | | - Michel Calò
- CTO Hospital, Città della salute e della Scienza, Turin, Italy
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